SOS (Save Our Students) Bully Tip Form
This form is used to submit tips on harassment, intimidation and bullying. Bullying is when a person or group of people repeatedly cause hurt or harm to a person or group of people who feel helpless to respond.
Role of person completing form
Pin Oak Student
Pin Oak Parents
Community Member
Targeted Student's Name (victim)
Your answer
Incident Date
MM
/
DD
/
YYYY
How did you learn about the bullying
Your answer
Did a physical injury result from the incident
Yes
No
Describe any physical injuries if they occurred.
Your answer
Why do you think the harassment, intimidation or bullying occurred?
Your answer
Name of school adult you've already contacted (if any)
Your answer
Name of Bully or Bullies
Your answer
What Happened?
Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
Getting another person to hit or harm the student
Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc
Putting the student down and making the student a target of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Making the student fearful, demanding money or exploiting
Spreading harmful rumors or gossip
Cyber bullying (bullying by calling, texting, emailing, web posting, etc)
Where did the incident happen?
Hallway
Bathroom
Playground
Classroom
School Bus
Gym
Lunchroom
Parking Lot
During a School Activity
Internet/cell phone
Off school property
Other
Witness(es)
Your answer
Name of reporting person (unless wish to remain anonymous)
Your answer
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This form was created inside of Henderson County Board of Education.
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